Prevention of contractures

Contracture of a joint following a limb amputation is a common complication, affecting about 3% to 5% of lower limb amputations, and can begin within days the procedure. When associated with limb loss, contractures occur most often in the joints closest to the amputation, for example, the hip with a transfemoral (above the knee, or AKA) amputation and the knee for a transtibial (below the knee, or BK) amputation. Understandably, caring for the surgical wound and pain management are foremost following such a significant surgery, but contracture prevention should also be an immediate post-operative consideration in order to maximize a patient’s potential post-amputation mobility.

Why contractures occur

When a limb is removed, the joint above the limb is no longer subjected to the pull of the limb’s muscles and tendons and the joint naturally pulls up or inward. As a result, contractures may begin while patients are still recovering and on bed rest, with limited access to range-of-motion exercises. “Every patient probably has a little bit of a contracture,” says Robert Burcham, a licensed prosthetist and a transfemoral amputee himself. Based on his practice, Burcham estimates that about 9 out of 10 people with transfemoral amputations have some degree of contracture. Unfortunately not many patients are aware of this possibility, which is likely why it’s so common, he says.

Preventing contractures

Prevention of contractures through teaching of joint exercises can begin before surgery. However, many who lose limbs are quite ill or are dealing with multiple medical problems, making preoperative instructions impossible. This means the physical therapist must step in as soon as possible following surgery for both education and exercise. Stretching and positioning of a joint is paramount in post-operative care, but it’s also important to encourage the patient move the joint throughout the day as one would during normal activity. Bed rest, which usually includes sitting with the head of the bed up several degrees contribute to contractures. Moving a patient from the bed to a wheelchair or bedside chair can produce similar effects.

There are many exercises that can be done aside from the range-of-motion exercises. Here are a few examples:

Approaches

Transfemoral amputations

“What I always recommend to patients is to rest on their stomach as much as possible,” Burcham explains. “Stretch out those hip flexors. Whether you’re watching TV in bed or on the couch, flip over and lie on your stomach. You want to extend as much as you can.”

Another is the adductor stretch: Your patient sits up against the head of the bed or on the floor against a wall. The amputated limb is positioned to the side as much as possible and the other leg bent, bringing the foot in towards the body. Keeping both buttocks down, your patient places a hand on each thigh and pushes down gently until a stretch is in the back of the thigh. Remind the patient not to bounce and to not lift one buttock higher than the other.

Transtibial amputations

The simplest exercise has your patient sitting up in bed or on the floor, with both legs straight out in front. Your patient then tightens the thigh muscles, pushing the back of the knees into the bed or floor. Hold this for 5 or 10 seconds, relax. Repeat.

Knee flexion, for both legs, can also be helpful. Have your patient roll on to his or her stomach. Both thighs should be making contact with the bed or floor. Your patient should then bend one knee back as far as is comfortably possible and hold this position for 5 to 10 seconds. Repeat with the other leg.

With all the issues that surround amputations, both physical and psychological, many patients may not be aware of the seriousness of contractures and the impact they can have on their quality of life further down the road. “Not a lot of patients are aware of the risk,” Burcham says. “They become aware of it when they get to the point of a 20 or 25 degree flex contracture.” As part of PT practice, it’s vital that the patients understand the risk and that PTs can help them learn how best to prevent or minimize contractures.